What do you envision when you think of rural living? Chances are, images of pastoral fields, idyllic red barns, and even herds of dairy cows come to mind.
While such a vision is a reality for at least some of the 60 million Americans who live in rural areas — sparsely populated regions confusingly described by the U.S. Census Bureau as “not urban” — living in a rural area has its downsides when it comes to healthcare.
Lack of access to high-quality, affordable healthcare providers plagues rural America. One main reason is that hospitals located in low-population regions face significant financial struggles. According to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill, 132 rural hospitals shuttered their doors since 2010, leaving many Americans with fewer care options.
Unsurprisingly, COVID-19 has only accelerated rural hospital financial hardship, potentially making in-person office visits even more of a herculean challenge.
Technological innovations, including in-app communication and HIPAA compliance, enable telemedicine to become a must-needed lifeline for rural communities requiring medical care and guidance. In short, tech is shifting the healthcare landscape for the better.
Telemedicine, defined as the practice of using technology to deliver care at a distance, is mitigating and sometimes wholly eliminating long travel times required to visit a rural healthcare facility. Via the use of HIPAA-compatible live chats, video meetings, and phone calls, people living in sparsely populated areas receive quality care and guidance from the comfort of their homes.
By Troy Corley, executive vice president of service delivery, Proactive MD.
In an ideal world, individuals would be able to access health care services in a quick and convenient manner — regardless of where they live. However, entirely too many residents in rural areas face a variety of barriers to access, limiting their ability to obtain the health care they need.
For many patients living in rural areas, having to drive for more than an hour just to see the nearest primary care practitioner is entirely too common. Because of this and other barriers, patients are generally not equipped to be proactive and preventive with their health due to the significant investment required to receive basic care.
Making matters worse, rural patients often face traditionally higher rates of poverty and are less likely to have health insurance than their urban counterparts. These economic challenges, in combination with higher rates of underlying chronic disease, make rural patients more likely than city dwellers to face poor health outcomes and suffer complications from heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke.
Today, about 60 million Americans, or nearly 20% of the U.S. population, live in Census-defined rural areas. And with the U.S. Department of Health and Human Services reporting only 39.8 primary care physicians are available per 100,000 people in rural populations, the gap in care between rural and urban Americans is only growing wider. The provider shortage — coupled with increased transportation challenges, social inequities, and the additional access barriers brought about by COVID-19 — makes physical access to care extremely difficult for many rural communities.
The Rise of Telehealth
While the current pandemic has forced the U.S. health care system to face numerous challenges, it has catalyzed the rapid adoption of telehealth services to safely deliver care at a distance.
As patients embrace this digital transformation, health care providers are beginning to look outside of their traditional base to reach new patients in unexpected locales. Employing telehealth services reduces access barriers for patients in rural areas, allowing them to receive basic care regardless of how far they live from a physician’s office.
By Dr. Donald Voltz and Eric Tran, master of science in microbiology and immunology, School of Medicine, Tulane University, New Orleans, LA.
The COVID-19 virus is ravaging the planet at a scale not seen since the infamous Spanish Flu of the early 1900s, inflicting immense devastation as the U.S. loses more than 200,000 lives and counting.
According to CDC statistics, 94% of patient mortalities associated with COVID-19 were simultaneously suffering from preexisting conditions, leaving a mere 6% of victims with COVID-19 as their sole cause of death. However, while immediate prospects for a mass vaccine might not be until 2021, there is some hope.
The fact that four in ten U.S. adults have two or more chronic conditions indicates that our most vulnerable members of the population are also the ones at the greatest risk of succumbing to the pandemic.
Healthcare providers must pay close attention to patients harboring one of 13 chronic conditions believed to play major roles in COVID-19 mortality, particularly chronic kidney disease, hypertension, diabetes, and COPD.
Rural populations are some of the most vulnerable and must be supervised due to their unique challenges. The CDC indicates 80% of older adults in remote regions have at least one chronic disease with 77% having at least two chronic diseases, significantly increasing COVID-19 mortality rates compared to their urban counterparts.
Health behaviors also play a role in rural patients who have decreased access to healthy food and physical activity while simultaneously suffering high incidences of smoking. These lifestyle choices compound with one another, leading to increased obesity, hypertension, and many other chronic illnesses. Overall, rural patients that fall ill to COVID-19 are more likely to suffer worsened prognosis compared to urban hubs, a problem only bolstered by their inability to properly access healthcare.
The recent global medical crisis forced people into isolation and even quarantine environments. It also revealed weaknesses in such areas as medical translation and interpretation services that were previously viewed more as a matter of convenience rather than as an absolute necessity.
There is talk today of an imminent second wave of the Coronavirus crisis and further lock-downs and more extensive isolation being put in place to stem the spread of the virus. Is the telehealth industry ready for a new wave? What weaknesses in remote health care remain to be addressed? What does the future of telehealth hold to help not only in times of crisis but in everyday life?
Remote Healthcare, Telehealth, and Medical Interpretation Services
There was a time in the not-so-distant past, and even to this day in many cases, where medical interpretation services are seen as more of a nuisance than they are a real benefit. In the United States, this is especially common with Spanish interpretation but remains a common occurrence that can be effectively resolved with remote medical interpreters and other telehealth solutions. The role of remote medical interpreters should increase in use and importance in the world of telehealth and telemedicine.
The role of the medical interpreter can be exceptionally challenging, especially given the lack of specific knowledge regarding medical terminology. In lieu of a more pleasant sampling, the example here will focus on the specificity of relevant medical terminology that is especially important given the nature of the coronavirus pandemic.
When individuals are gathered in a more informal conversation regarding colds, cases of flu and COVID-19, they may refer to a more generic word like “spit.” In reality, this is not so much a medical term as phlegm, saliva, and mucus, all three of which have a more specific medical meaning, and all three of which are very relevant to a proper diagnosis and treatment, most notably in terms of any potential respiratory disorders such as those produced by the Coronavirus family.
Any time when someone who is not a professional or certified medical interpreter is used, there is an increased risk that the precise medical meaning of the term may not be fully understood in either language, and the incorrect translation will result in a misdiagnosis.
Struggling rural hospitals face financial pain amidst the coronavirus outbreak. Revenue has been lost as elective procedures have been canceled since patients can’t safely visit in person for fear of being infected or spreading the disease. As a result, rural communities may lose access to critical care as the pandemic progresses.
Rural residents hurt
The financial and operational pressures on rural healthcare facilities can leave patients who are displaying COVID-19 symptoms or require ongoing care for chronic conditions with limited access to critical care, especially considering many rural residents live more than 30 miles away from the nearest hospital. Plus, rural populations are often more vulnerable to severe to serious outcomes with COVID-19. Compared to urban populations, rural Americans:
Are older: More than 20% of the population in completely rural counties are ages 65+, according to U.S. census data, compared to around 15% in mostly urban centers.
Have higher rates of: obesity, diabetes, high blood pressure, and cigarette smoking
Have increased mortality rates from: heart disease, cancer, lower respiratory disease, stroke, and unintentional injuries.
Technology must be used to solve the problem
Mobile, Alabama-based healthcare technology company CPSI understands the challenges facing rural hospitals and clinics, so the company is providing a free telehealth portal so doctors can continue to provide quality care.
While telehealth regulations were quickly changed amidst COVID-19, allowing providers to be reimbursed at $220 per remote appointment instead of at $13, telemedicine is not a reality for cash-strapped rural hospitals that:
Lack the technological infrastructure and resources required to implement telemedicine
Require a highly secure, HIPAA-compliant platform (Zoom, Skype, Microsoft Teams are not secure options)
Need a platform that operates smoothly on low-bandwidth connectivity, common in rural areas
Treat patients who don’t have computers or webcam capabilities
Rural hospitals need an affordable, secure, easy-to-use telehealth platform that can be set up in hours, not months, to give their patients quality care while allowing them to tap into a desperately needed revenue stream that could help them stay afloat. They need CPSI’s turnkey telehealth solution: Talk With Your Doc.
Connected Nation (CN), through its state program Connected Nation Michigan (CN Michigan), released a study that examines the use and perceptions of telehealth in rural areas with a focus on Michigan counties.
Researchers found, among other things, the highest ratios in the country of patients per doctor, a lower-than-average life expectancy, and a higher-than-average number of preventable hospital stays in rural states with restrictive telehealth policies.
“This study demonstrates why connecting rural America is critical,” said Tom Ferree, chairman & CEO, CN. “Connected Nation has worked for nearly two decades to identify innovative solutions for connecting every community, and in that time, we’ve seen firsthand that having access to high-speed internet impacts everything from the economy to educating our children. Now we have real data that shows it can also impact healthcare—and even life expectancies—among families and individuals in our rural communities and small towns through telehealth applications and programs.”
The more than six-month-long study was done in partnership with AARP and the Michigan Health Endowment Fund. Find the full report at http://bit.ly/2ThWBPX. The study looks at the opportunities and reasons for expanding telehealth as well as the obstacles for rural areas.
“Many older adults in Michigan, especially those who live in rural areas, do not have access to high-speed internet, and that’s a quality-of-life issue for them,” said Paula D. Cunningham, State Director of AARP Michigan. “That means they can’t take advantage of advances in telemedicine that at the very least could save them long trips to the doctor, and at the most could be lifesaving.”
“Our nonprofit has long been focused on connecting more families and communities to high-speed internet,” said Eric Frederick, executive director, CN Michigan. “In recent years, we’ve seen more talk about the ways telehealth could help fill the void in rural areas where there may not be hospitals or doctors for hundreds of miles. But, as we looked around for more detailed information on telehealth in Michigan, we soon learned there were a lot of unanswered questions at the intersection of telehealth and the digital divide that we decided to set out and answer—from how state policies impact the use of technology to whether people or providers even understand the many ways it can be used.”
CN Michigan’s researchers took a three-pronged approach to examine those issues. First, they reviewed the current telehealth policies in all 50 states to identify counties ripe for leveraging the benefits of telehealth. As part of this analysis, CN Michigan compared each county’s access to primary care physicians and health outcomes to determine how big of a role telehealth policies and the Digital Divide play in these metrics.
Second, the team conducted telephone surveys of 2,001 adult heads of households in five rural Michigan counties: Gladwin, Sanilac, Roscommon, Osceola, and Dickinson.
“We chose these five counties because they represent a cross-section of rural portions of the state,” said Chris McGovern, Director, Research Development, Connected Nation (CN). “They were selected due to their differences and representative nature in terms of geography, employment, and the prominence of non-related healthcare provision networks in each county. We focused our questions on current telehealth usage, savings experienced from accessing online healthcare, interest in future use of telehealth services, and barriers that prevent individuals from using the technology.”
The third facet of this study focused on healthcare providers. CN Michigan conducted extended interviews and focus groups with healthcare networks, including doctors, nurses, medical assistants, and others within the five counties identified for telephone surveys. Healthcare networks in these groups ranged from just beginning to experiment with telehealth to those with established and award-winning telehealth programs.
“Although our focus was primarily on the impact in rural Michigan, this data can help inform the development of telehealth services elsewhere and provide a starting point for additional studies in regions across the United States,” said Frederick. “Our hope is to build upon what we’ve learned in this study and help more people in both rural and urban areas save time and money through telehealth applications and expanding broadband access. Most importantly, we hope it will lead to innovations that can improve the quality of life for all Americans—no matter where they live.”
Today, the Trump Administration proposed changes to further the agency’s priority to transform the healthcare delivery system through competition and innovation while providing patients with better value and results. The proposed rule would update Medicare payment policies for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for fiscal year 2020 and advances two key CMS priorities, “Rethinking Rural Health” and “Unleashing Innovation,” by proposing historic changes to the way Medicare pays hospitals.
“One in five Americans are living in rural areas and the hospitals that serve them are the backbone of our nation’s healthcare system,” said CMS Administrator Seema Verma. “Rural Americans face many obstacles as the result of our fragmented healthcare system, including living in communities with disproportionally higher poverty rates, more chronic conditions, and more uninsured or under insured individuals. The Trump Administration is committed to addressing inequities in healthcare, which is why we are proposing historic Medicare payment changes that will help bring stability to rural hospitals and improve patients’ access to quality healthcare.”
The inpatient hospital wage index specifies how inpatient payment rates are adjusted to account for local differences in wages that hospitals face in their respective labor markets. It is intended to measure differences in hospital wage rates across geographic regions and is updated annually based on wage data reported by hospitals. Hospitals located in areas with wages less than the national average receive a lower Medicare payment rate than hospitals located in areas with wages higher than the national average. For example, a hospital in a rural community could receive a Medicare payment of about $4,000 for treating a beneficiary admitted for pneumonia while a hospital in a high wage area (like many urban communities) could receive a Medicare payment of nearly $6,000 for the same case, due to differences in their wage index.
In last year’s proposed rule, CMS invited comments on changes to the Medicare inpatient hospital wage index. Many responses reflected a common concern that the current wage index system makes the disparities between high and low wage index hospitals worse. High wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals. Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index hospitals and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals declines.
To address these disparities, CMS is proposing to increase the wage index of low wage index hospitals. This change would ensure that people living in rural areas have access to high quality, affordable healthcare. CMS is considering several ways to implement this change, and the agency looks forward to comments on the different approaches.
The Trump Administration is also announcing proposals that would ensure Medicare beneficiaries have access to a world-class healthcare system by unleashing innovation in medical technology and removing potential barriers to innovation and competition in order to expedite access to novel medical technology.
“Transformative technologies are coming to the private market, but Medicare’s antiquated payment systems have not contemplated these technologies,” said Verma. “I am particularly concerned about cases that have been reported to the agency in which Medicare’s inadequate payment has led hospitals to curtail access to needed therapies. We must continually update our policies in response to the rapid pace of advancement in medical science.”
How do you provide care to underserved patients who have difficulty getting to the office? This was the challenge we were trying to solve at the Clark Clinic. Some of our patients don’t have access to a vehicle or are physically restricted and unable to travel far. But, as most of our community is underserved, we needed to collectively identify a solution to ensure we can serve all our patients.
I knew from conversations with other healthcare executives that telemedicine was the solution. I recently learned of a pediatrics office in Jacksonville that uses telemedicine to serve its ADHD patients better. Like the Clark Clinic, its patients found it difficult to comply with required visits. Telemedicine allowed ADHD patients to conduct their appointments remotely. Rates of visit compliance skyrocketed. We realized then that telemedicine technology would be ideal for a rural community.
We have experienced seismic shifts in the popularity of telemedicine. Technology has largely influenced every aspect of our society. With instant access to every component of life, people are developing a dependence on technology. In healthcare, patients want easy and efficient access to healthcare, without having to wait for hours in the office. After a telemedicine visit, they are convinced of its value. The process is simple — download the healow TeleVisits app and schedule an appointment. There is no doubt patient satisfaction has improved.
At the Clark Clinic, our slogan is “We are wherever you are” and telehealth allows us to provide the same level of care no matter where our patients are located. With multiple clinics across central Florida, our doctors are often on the road. There have been various situations where patients had urgent visits but couldn’t be seen because our doctor was miles away. But with telemedicine, the doctor can schedule a remote appointment and conduct and treat patients in need while maintaining the established provider-patient relationship. Amazingly, our physicians have even noted that in most cases they are able to make accurate judgments, all from observing a patient’s speech, breathing, motions, and mood.
Our patients who reside at local assisted living facilities also love the convenience of telemedicine. These individuals appreciate the ability to download the app directly onto their phone or tablet and schedule an appointment with their doctor. Typically, they take the call in their room, and all their health questions are quickly answered. We’ve also heard from their families and loved ones, who enjoy the reassurance that, with telehealth, the level of care never wavers and access to quality care is not limited.
Rural healthcare organizations and their patients are up against a myriad of challenges, from minimal funding and resources to limited access to care, social determinants of health, and more barriers that stand in the way of effective care delivery. Unfortunately, nearly half of rural hospitals operate at a negative margin and are struggling to survive, according to iVantage’s 2017 Rural Relevance Study.
The number of rural hospital closures has risen to 87 in the last eight years, according to the National Rural Health Association (NRHA). The closures create a large gap in healthcare resources available in rural communities, as the residents cannot always drive or fly great distances to access needed care. Virtual care technology can address gaps in care and help rural providers continue to deliver care for the vast populations and geographies they support.
Increased re-admission rates amongst rural patients are driven by inadequate care and support after the patient returns home. Home health organizations now play a critical role in helping hospitals reduce these rates by providing care to rural patients, especially during the initial thirty days after discharge. Home health organizations are actively implementing virtual care platforms to automate the post-discharge follow-up with a rural patient by sending reminders to schedule appointments for post-discharge virtual visits via the communication channel of the patient’s choice – e.g., text, SMS, email or even a phone call. Follow-up care can be provided in a cost-effective video call (for home health providers and patients) which optimizes the caregiver’s productivity by minimizing excessive transportation time, travel costs and related liabilities typically associated with driving to/from patient homes.
To help home health agencies, there has been a longstanding Medicare rural add-on for home health services. Federal add-on payments through the Center for Medicare and Medicaid Services (CMS) have been crucial to these agencies operating in rural regions of the country. The 3 percent payment modifier to reimbursements for services provided in rural and underserved areas helps these agencies which face higher overhead expenses through factors such as increased travel time between patient visits and demands for extra staff. This payment modifier is imperative so that rural agencies will be able to keep their doors open and provide necessary care to home-bound patients.
However, the Centers for Medicare & Medicaid Services (CMS) has proposed payment rules which may impact the delivery of home health care in rural communities. The shift was mandated by the Bipartisan Budget Act of 2018. Under the new methodology, CMS is varying add-on amounts depending on a rural county’s home health utilization, population density and other factors. Unlike the current standard of a 3 percent three percent rural add-on, CMS’s proposed payment rule segments counties into “high utilization,” “low population density” and “all other” categories:
High-utilization counties are “rural counties and equivalent areas in the highest quartile of all counties and equivalent areas based on the number of Medicare home health episodes furnished per 100 individuals who are entitled to, or enrolled for, benefits under part A of Medicare or enrolled for benefits under part B of Medicare only, but not enrolled in a Medicare Advantage plan under part C of Medicare.” Low population-density counties are designated due to their population density of six individuals or fewer per square mile of land. The all-other category includes counties and areas that don’t fit into either definition.
Although life in rural communities offers many advantages, the rural healthcare system in America faces challenges not seen in urban areas, for obvious reason: population loss, poverty and access to healthcare have been problematic in recent years.
Taking a look at Pennsylvania, which is the sixth most populous and ninth most densely populated state in the US, based on information from the United States Census Bureau from 2010 and 2013, as a state it hosts a significant amount of rural areas. According to the Pennsylvania Rural Health Association, 48 of its 67 counties classified as rural, and all but two counties have rural areas. More than one quarter of Pennsylvanians live in rural counties.
Thus, it’s as good a place as any to examine some of the unique issues facing rural communities, who even though they may be within driving distance to some of the best medical care in the world, they are unable to access it each day without some sort of life altering obstacle.
In general, residents of rural communities in the U.S. are less healthy than those in urban environments. According to Unite for Sight, “rural residents smoke more, exercise less, have less nutritional diets and are more likely to be obese than suburban residents.” Already against the odds, residents in rural Pennsylvania face several specific problems that jeopardize the state of healthcare in the area.
Between 2000 and 2010, the Pittsburgh Post-Gazette reported that rural Pennsylvania counties grew by 2.2 percent while urban counties grew by 3.9 percent. However, the small increase in rural counties was only because of the eastern counties. Western rural counties decreased by 0.9 percent, and by another 0.5 percent from 2010 to 2012.
In some places, the situation is bleak. The newspaper highlights the population loss in Taylor Township, a part of Lawrence County that experienced a 13.6 percent population loss from 2000 to 2010. “Of its 1,052 residents, more than twice as many are over age 65 as under 18. That ratio is practically unheard of among municipalities and doesn’t bode well for the township’s future.”